Full Name

Today’s Date

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Date of Birth

Home Address

City

State

Zipcode

Email

Is it OK to contact you via email?
YesNo
OK to leave a message? (email)
YesNo
Phone Number

Is it OK to contact you at this number?
YesNo
OK to leave a message? (phone)
YesNo
How did you learn about the psychotherapy services provided at this office

Reason for seeking treatment

What has happened to cause you to seek help now?

What do you hope to be able to do or achieve as a result of treatment?

How do you handle stressors and/or cope with the problems you have described

Reason for seeking treatment (checkbox/selection)
Initial consultation (brief meeting to assess fit and goals)Ongoing individual therapy

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